Exclusive ATA Video Highlights

More Effective Approach to Pediatric Thyroid Nodules

While thyroid nodules occur less often in the pediatric population than among adults, when a nodule is detected, the risk for malignancy has been estimated at 4 to 5 times the rate seen in adults.1 In adults, the incidence of thyroid tumors has been estimated at 5% and 15% whereas, in children, an estimated 9.2% and 50% of diagnosed thyroid nodules were estimated to become malignant.2

There is evidence to suggest that the incidence of thyroid tumors is on the rise in the pediatric population,3 a concern that has gained attention since managing thyroid cancer in children presents a greater challenge than treatment in adults,4 according to Andrew J. Bauer, MD, Medical Director of the Pediatric Thyroid Center at Children's Hospital, and associate professor of pediatrics at the University of Pennsylvania Perelman School of Medicine, both in Philadelphia.

While there has been a tendency toward surgery and radioactive iodine imagining (RAI) treatment both of which harbor risk for complications, an acknowledgement that key differences exist in the way the pediatric population responds to the most common treatment strategies was a huge leap forward in changing the approach to clinical management of children who were diagnosed with a thyroid nodule.4

Diagnostic advances, in particular, biopsy by fine needle aspiration with molecular testing, has led to an improvement in the assessment of nodules as benign or malignant, allowing for surgery to address primarily cancerous nodules.

Prior to 2015, the only guidelines available to practitioners were recommended approaches to management of thyroid nodules and differential thyroid cancers in adults.5 Then, the American Thyroid Association commissioned a task force to review the scientific literature to evaluate and treat thyroid nodules in the pediatric population as a basis for developing guidelines directed to the particular needs and concerns of this young population.6

These guidelines focused on methods to identify those patients under age 19 who may be most at risk for persistent disease.6 The ATA pediatric risk classification guidelines stress the need to institute a greater attentiveness to the diagnosis of nodules and introduce a risk stratification to more clearly identify which patients might be appropriate candidates for RAI.

During the 87th Annual Meeting of the American Thyroid Association, Dr. Bauer opened the satellite program, Update on pediatric thyroid disease 2017: Current state and future directions;4 he shared highlights of the forum with EndocrineWeb.

Currently, Dr. Bauer and his research team at Children’s Hospital of Philadelphia, have been examining thyroid tumors in the pediatric population to ascertain common features that may be predictive for cancer risk,7 among several research studies underway.

Julie Ann Sosa, MD, FACS, chief of endocrine surgery and a professor of medicine and surgery specializing in oncology at Duke University Medical Center in Durham, North Carolina, was honored with the 2017 Lewis E. Braverman Distinguished Lectureship Award at the 84th annual meeting of the American Thyroid Association which was held in Victoria, British Columbia. Her presentation addressed the potential risks from exposure to flame retardants and the rising rates of thyroid cancer, "Retelling the story of thyroid cancer—Rising incidence, mortality, and maybe an explanation."1

As concern about the harmful effects of a growing number of endocrine-disrupting environmental chemicals continues to grow, Dr. Sosa and colleagues studied the risk of thyroid dysregulation and cancer from exposure to products treated with flame retardant chemicals. To reduce consumer harm from fires, 1.5 millions tons of these chemicals have been applied to commonly used household items, children's toys, and pajamas. Widespread application of flame retardants has become so ubiquitous in the environment that it is now showing up in measurable levels in human tissues,1,2 according to Dr. Sosa.

Given the evidence linking endocrine-disrupting chemicals, such as bisphenol A and polychlorinated biphenyls, Dr. Sosa and colleagues sought data on the potential harm presented by repeated exposure to the newest flame retardant chemicals, specifically polybrominated diphenyl esters.

The results, published in Current Opinions in Oncology.2 suggest an adverse impact on thyroid regulation from repeated exposure to these newer flame retardant chemicals, raising concerns about a likely role in increasing rates of thyroid dysfunction and risk of thyroid cancer.

The Braverman lecture award recognizes an individual who "demonstrates excellence and passion for mentoring fellows, students, and junior faculty, has a long history of productive thyroid research, and is devoted to the American Thyroid Association.

"Dr. Julie Ann Sosa embodies the spirit of the Lewis E. Braverman Distinguished Award in her passion for selfless mentoring of others, her long and valuable intellectual efforts in the field of thyroid research, and her energetic devotion to the ATA," said the ATA award committee.

Since Dr. Sosa joined the Duke University Medical Center in 2013, she has continuing to focus on thyroid cancer research with an equal devotion to training medical students, interns, residents, and fellows. Over her 10 years at Yale University, she progressed from an assistant to an associate professor of surgery to director of the clinical health services research group in endocrine surgery, to leader of the clinical research program in endocrine cancers at the Smilow Cancer Hospital at Yale in New Haven, Connecticut. She received her medical degree from the Johns Hopkins University School of Medicine in Baltimore, completing both a residency and internship in general surgery at Johns Hopkins Hospital.

Over the years, Dr. Sosa has mentored more than 60 physicians, many of whom collaborated with her on research, scientific presentations, published articles, during which she gained a reputation as the "ultimate mentor for anyone who desired a solid foundation in research and publications. Her extensive research on the management of benign and malignant thyroid diseases. Most recently, Dr. Sosa was lead investigator on a study that was the first to gather data on which surgeons achieved the lowest risk of patient complications based on the total number of thyroidectomies conducted annually by surgeons published in the Annals of Surgery, which earned the recognition as the most viewed paper published by that journal in 2016.
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Dr. Wartofsky shared the latest results on the role thyroglobulin levels may play in managing patients following thyroid surgery to inform future care. Here he offers a takeaway message following his session at the American Thyroid Association annual meeting. A full summary of his presentation will be available on EndocrineWeb early next week.

Wartofsky L. Employing thyroglobulin assay for risk stratification in the management of differentiated thyroid cancer. Presentation at the 87th Annual Meeting of the American Thyroid Association. October 18-22, 2017. Victoria, British Columbia, Canada.